The lifestyle challenge

This program will be broadcast in front of an audience from the Powerhouse Museum in Sydney, as part of the Ultimo Science Festival. Three leaders in the field of exercise, nutrition and psychology will take part in the discussion about lifestyle challenges. Questions which will be discussed are: Feeling the need for a new lifestyle? Wondering about the five by two diet? Is interval training all it's cracked up to be? And how do you shift your mindset so you're able to live healthier?

Transcript

Norman Swan: Hello, and welcome to the Health Report, coming to you tonight live from the Powerhouse Museum in Sydney.

[Applause]

Yes, a Health Report in front of a live audience. And tonight we're going to be talking about the lifestyle challenge. Feel in need of a new lifestyle? Wondering about the five-by-two diet? Is interval training all it's cracked up to be? And how do you shift your mindset so you're able to live healthier? And in fact do you want to live healthier or are you actually just into body sculpting and looking better? All those topics tonight in the Health Report with an expert panel.

Our expert panel includes: Professor Bronwyn Kingwell from the Baker IDI Heart and Diabetes Research Institute in Melbourne, an international authority on exercise, its benefits and the various types of exercise we might take; Professor Peter Clifton who is professor of human nutrition at the division of health sciences in the School of Pharmacy and Medical Sciences at the University of South Australia in Adelaide, co-author of the CSIRO diet, an endocrinologist, a diabetologist, and, as I've already said, a human nutritionist; and last and certainly not least, Professor Prasuna Reddy, a psychologist who is in the School of Medicine and Public Health at the University of Newcastle. Could you please welcome our panellists?

[Applause]

If we have time towards the end of the program we'll take some questions from our live audience. I just want to start with you, Prasuna, about what brings people to the lifestyle challenge, what sort of crisis is it? Is it a mistress or is it a health issue or what? Or a lover?

Prasuna Reddy: Could be. We were just discussing a moment ago whether you are motivated by happiness or by other factors. Quite often it's a point where something has to change. And yes, it could be a crisis, but it could also be a pleasant event, something that makes you feel good about being yourself. The birth of a child can often be an opportunity for you to change things that you may have been in the habit of doing.

Norman Swan: But of course it can also create abnormal behaviours, the desire for lifestyle change, because you can get it in adolescence because you decide as a young male you want to lose weight and have a Brad Pitt abdomen, and the parallel for young women who see thin waifs in the women's and young girls' magazines.

Prasuna Reddy: There's no doubt that there is a lot of pressure on us from social media, from external cues. True behaviour change has to be internal, but getting there is tough.

Norman Swan: So we'll come back to how we get there, but we'll get the menu of where we might get to first.

Bronwyn Kingwell, it's the same with diet (we're going to come to Peter Clifton in a minute), every time you open the paper or turn on the television you see something new. So, different ways of doing weight training. I saw in the New York Times rowing has become the latest fad in American gyms. You hear about interval training. Just take us through what's on offer and what is roughly the evidence for it. Let's start with interval training.

Bronwyn Kingwell: I think what you need to consider is what do you want to achieve from your exercise. And as you said, is it the body beautiful? Is it…

Norman Swan: I'd like to get away from the pinot noir to the six-pack, I think.

Bronwyn Kingwell: Yes, and I think a lot of us are here to talk about health benefits, but other people are performing exercise to improve their performance as well. And so the type of exercise you choose really depends on the objective you have. But let's talk about interval training, since you raised it. There's a big focus on interval training, and for those of you who don't know, this is performing exercise at a high intensity for a short period of time and then having a break of lower intensity or no exercise. So it could be a minute on, a minute off, it could be 30 seconds on, four minutes off, there's infinite combinations really, and different combinations will achieve different effects.

Norman Swan: And when you're on, you're really on.

Bronwyn Kingwell: You're really on, yes. So high intensity interval training is as hard as you can go. And look, we've known for years since the 19th century really that this type of training has benefits for performance. It allows you, if you train like this, to then when you do go out for a continuous bout of exercise to perform at a higher level for a longer time. So in terms of performance, yes, this type of training works. But I think that the question that we need to ask now is does it work in terms of health benefits and reducing risk factors for diabetes and cardiovascular disease.

Norman Swan: And do we know?

Bronwyn Kingwell: We're starting to get some evidence. So I think we've got very good evidence now that interval training does have benefits in terms of reducing risk of diabetes, so glucose control, and this really make sense because high intensity interval training uses glucose as the major energy source to produce the muscle contractions for exercise at those really high levels. So it improves glucose control, definitely. Does it lower blood pressure, does it improve your lipids? I think the jury is still out on some of those aspects.

Norman Swan: Your research some time ago showed that if you just do the recommended exercise, 30 minutes on a regular basis, 30 or 40 minutes on a regular basis, particularly of aerobic exercise, in that case that is quite potent at reducing your blood pressure.

Bronwyn Kingwell: Absolutely, it reduces blood pressure to the extent of a lot of drugs that are used currently to lower blood pressure. So this is doing 30 minutes three times a week at a moderate type of intensity. And I think what we don't know about the interval training at the moment is particularly whether you get some of the cardiac adaptations and the adaptations that we know as athletes heart, the enlargement of the heart, because that type of interval training is not loading your heart for those longer periods of time.

Norman Swan: The theory is that it's all about stress, and my understanding from animal research, when you stress the animals with what could be the equivalent of interval training, they actually get nerve growth in the brain.

Bronwyn Kingwell: There are all sorts of effects of stress and there are studies showing, for example, if you are stressing animals with high-intensity exercise, that sometimes you don't get the blood pressure reductions and things too, because it is not something they enjoy. And this is something that we might want to discuss as a panel too, that I think the bottom line for exercise choice comes back to something that you enjoy doing.

Norman Swan: So what about progressive training? People think, well, I'm going to get off my bum, I've been sitting on my bum and I get off my bum and I'm going to go out for a walk, versus progressive…making it harder for yourself as it goes on. So this isn't interval training, it's actually building up your level of exercise as you go along. My understanding is that for all the benefits that are advertised for exercise, you've really got to progress, you've actually got to work your body harder.

Bronwyn Kingwell: You'll get some benefits with low-level exercise, with things like walking, and there is some evidence that there is even some blood pressure reduction and so forth with walking, but if you want to continue to improve and continue to improve performance, change some of your risk factors for heart disease, it's good to progress. And I think it can be good psychologically for people to see progression. But what happens is the different risk factors for heart disease have different dose response relationships with exercise. Some kick in at a low point, some you need to do more exercise to have an effect on, for example, cholesterol, and your good cholesterol levels usually take quite a lot of exercise to actually have them rise.

Norman Swan: And depression, Prasuna? I think for depression you've got to do quite a lot of exercise to actually get an antidepressant effect.

Prasuna Reddy: It does, and certainly we know that physical activity, especially if you have someone else to engage with, is beneficial for depression. What interests me though is has anyone looked at what people eat after such intense exercise? Because my understanding…

Norman Swan: You've got to spoil it, haven't you!

Prasuna Reddy: I was thinking, the human mind exists in a biological body, and the brain needs a source of energy, so if you are highly stressed, aren't you likely to crave sweets? You know, that conundrum that we're faced with…

Peter Clifton: In most of the exercise interventions people lose a little bit of weight, especially if it's very intense, and the less intense ones, their weight is stable. But in general when you look at the amount of fat they've got, their visceral fat has gone down by a kilogram or two and their muscle has gone up. So very few of the exercise published data show people gain weight. Obviously that doesn't mean individuals don't put on weight when they are exercising, but in large clinical trials people either are weight stable or lose weight, so they don't gain weight.

Norman Swan: And just finally, Bronwyn, before we move on, strength training and its role there? Because I think a randomised trial at the Baker IDI showed that that does prevent diabetes, so it has to be part of a cocktail.

Bronwyn Kingwell: It is, so strength training is very important, as you say, for prevention of diabetes. Muscle is the major sink in the body for glucose, and if you can build muscle, that certainly reduces your risk of diabetes. So you do need a variety of exercise to get a complete health benefit.

Norman Swan: Peter Clifton, we had a whole Health Report three or four weeks ago on the low carb diet, using the low carb diet to treat diabetes, how we've all been conned, it's not about calories, it's about what you eat, that's the Gary Taubes theory that we eat high calorie, low value foods which boost our insulin and it's our insulin that lays down fat, and all calories are not equal. It's a jungle out there when it comes to diets.

Peter Clifton: I think all calories are pretty equal.

Norman Swan: Damn!

Peter Clifton: I think that has been shown pretty convincingly, whatever Gary said, all calories are pretty equal. So the key when you are trying to lose weight, say to prevent diabetes or to improve your diabetes control, is being mindful about what you eat and being conscious all the time of what you are eating, and not depriving yourself so much that you have a desperate response to it. So you have to control and moderate your food intake in some way, it doesn't have to be a drastic reduction but you need to be aware all the time of what you are eating. So all of the various diets are just different ways of achieving this end, of trying to moderate your food intake.

So the strategies of either 20% or 30% calorie reduction every day, which is the CSIRO kind of diet, or the alternate-day modified fasting, or the five days of normal food and two days of fasting are just ways of getting an average caloric reduction over a week and sticking to it without feeling unhappy, without feeling dissatisfied, and something that can be maintained long-term. So that's the key. You can lose weight on any kind of strategy you like, but you need to be able to stick to this kind of pattern forever to keep your weight off.

Norman Swan: So you reject the notion that the low carb…that comes out of the Harvard School of Public Health and others, suggesting that we've traded fat for carbohydrates and that has not been a good thing?

Peter Clifton: What's happened in America is not that we've traded, fat has remained the same but carbohydrate intake has gone up. So the Americans have got fat predominantly on carbohydrates, it's true. They eat a lot of fat, but carbohydrates have gone up enormously, especially in beverages, sugar sweetened beverages, and Americans put sugar in everything, bread has got sugar in it, every single food product has got sugar in it.

Norman Swan: And fructose.

Peter Clifton: Well, fructose is an essential part of sugar, it's half of sugar. So it doesn't matter whether it's fructose or glucose.

Norman Swan: So you don't believe that fructose is more toxic than sucrose?

Peter Clifton: Not really, no. When you feed 40% of calories as fructose, which is a huge amount, you do see subtle changes in terms of liver fat and visceral fat, but in general it's the caloric burden that's the most important thing.

Norman Swan: Okay, so why the popularity of the low carb diet then? Because we had somebody on saying how much better their diabetes control was on a low carb diet.

Peter Clifton: Sure, well, he had type I diabetes which was brittle, so he found it very hard to balance…

Norman Swan: I should explain, this is a radiologist from the Sunshine Coast we had on who developed type I diabetes in his early 40s and had reduced his insulin intake from about 30-odd units a day to about six, and his hour-by-hour sugar control was much, much better.

Peter Clifton: Yes, so it's a good strategy, it is quite difficult to do, so you have to be, again, very mindful about what you are doing all the time. Some people with type I don't need to do it, but others are very brittle and their sugar goes up and down and they get hypos, particularly because they've overdosed themselves with insulin. So one strategy to try to reduce your risk of that happening is to just wind the carbohydrate back, and then you need to deliver less and less insulin. You still need to deliver some insulin otherwise you will die, but you need to deliver a smaller amount because of the smaller amount of carbohydrate you're eating.

Norman Swan: So it's not something you do suddenly.

Peter Clifton: No, you could do it suddenly, but it's hard to manage. You need to work out…

Norman Swan: So do you have many patients on it?

Peter Clifton: I usually…especially if they are brittle, I try to get them to manage it in that way, yes, so it's not an uncommon thing, and it has been advocated for the last 15 years, but there's a lot of rejection of it by diabetes educators. But it does work very well for some people.

Norman Swan: So I get two or three emails a day about the five by two diet. So five days of stuffing your face and two days of starvation.

Peter Clifton: No, no, not five days of stuffing your face, five days of normal diet…

Norman Swan: That's why it's not working!

Peter Clifton: That's right. And two days of a modified fast, so 500 calories rather than 2,500 to 3,000. So you are restricted during those two days off, but not enough to feel desperately hungry that you are going to go and grab a bag of chips. And you can choose low calorie density foods like strawberries and cherry tomatoes and get very few calories from those and feel quite satisfied orally, and most people manage the two days. It just depends what they do with their five days, whether they eat to excess to enjoy themselves. But if they just stick to their normal diet and do their two days of modified fast they will lose weight. But we don't know how long…

Norman Swan: What about the animal evidence which shows that you seem to get a much improved insulin response on this compared to just ordinary caloric restriction, and there seems to be lower levels of what they call technically an insulin-like growth factor, which seem to stimulate cancers. And there's a little bit of evidence for women with breast cancer that you get lower rates of recurrence. It's still preliminary evidence. What's your view on that, that it is a bit different because of the stress you give your metabolism?

Peter Clifton: I don't think anyone has shown long-term that it's beneficial. Certainly when you go on any kind of drastic caloric restriction, either a complete fast or a modified fast you become very insulin sensitive, so your insulin levels drop during that day. They will then go back to normal the next day, but what that does long-term I don't think anybody has any idea. But certainly you are more insulin sensitive on your fasting days because you have to be.

Norman Swan: So what's the diet that is best for maintenance?

Peter Clifton: I don't think there is a golden…it's the best for the individual. So for any individual it would be completely different, so I don't think there is one rule for anybody. How best you manage your constant awareness of what you eat and feel satisfied is what people need to find. You can not go back to what you were eating before because you will just put on weight.

Norman Swan: So this is the whole idea, you give up on the diet idea and you change the way you eat permanently.

Peter Clifton: That's right, it's got to be a permanent lifestyle, and some people could manage on a 6+1, so they have one modified fast, and six days of normal eating and maintain their weight. So if they've lost weight on two days of fasting, they can maintain their weight loss with one day of modified fast, but it has to be different from what they were doing before.

Norman Swan: And the synergistic effect of exercise? Is there a synergistic effect? I do The Biggest Loser every season, for my sins. They do an incredible amount of totally artificial lifestyle intervention, but it's amazing, their diabetes goes away.

Peter Clifton: Yes, so if you do 500 calories a day of exercise then obviously there is that 500 calories that you can eat without putting on weight. So it does add. But if you are trying to lose weight just with exercise alone, you've got to exercise an enormous amount, but you will lose some visceral fat, a kilogram or two, but you won't lose that much weight.

Norman Swan: And the pattern of eating, the difference it makes to move towards a more of a Mediterranean style diet versus meat and three veg?

Peter Clifton: Certainly the Mediterranean diet is associated with cardiovascular protection as well as less diabetes.

Norman Swan: We're talking about more white meat than red meat, more vegetables, probably not that much fruit.

Peter Clifton: Fruit and vegetables together, and legumes, much less meat of any sort, red and white, and fish, alcohol is an essential part of it. And when you actually look at the factors that predict mortality, alcohol is the one that came out as the most significant factor.

Norman Swan: For reducing mortality?

Peter Clifton: Yes.

Norman Swan: But in moderation.

Peter Clifton: With a moderate Mediterranean style, that's right. And then fruit and vegetables, yes, so it is regular one or two drinks each day. Fruit and vegetables were second.

Norman Swan: You're listening to the Health Report here on ABC Radio National, with me Norman Swan, and we are talking about the lifestyle challenge with Professor Bronwyn Kingwell, Professor Peter Clifton, and Professor Prasuna Reddy from the University of Newcastle.

Prasuna, just talk us through, because these are significant challenges. You're going to change your diet forever, you're going to change your exercise pattern forever. How do you do this? What's the pathway psychologically?

Prasuna Reddy: For all these kinds of changes it does require willpower and self-control.

Prasuna Reddy: Well, actually we have a finite amount of willpower, it just becomes depleted as we use it. So it is the same amount of willpower whether we are using some for dieting, some for exercise, some for working, some for dealing with a difficult person, other for being social, it's the same amount of willpower. So the more energy we put into one thing, the less we will have for another. And planning does require quite a lot of thinking and energy and so on. So what we'd like to do is develop plans so that controlled behaviour becomes automatic behaviour. In other words, we would like…

Norman Swan: So you save on your willpower, you put willpower in the bank, in a sense.

Prasuna Reddy: Yes, so that we are able to work automatically, that through planning we can then determine what we can call habits. So we can have good habits from unhealthy habits but it does require willpower.

Norman Swan: So talk me through this, because the bad habits occur from childhood. You know, we are watching ads that encourage consumption, we are not necessarily…there is a bit of evidence in terms of parenting that children who are taught how to delay gratification do better in life, they do better in school and various other things. So let's go through the lifestyle cycle. So you've been indulged, you've eaten anything you've liked, and how do you regain good habits when you've had bad habits for 30 or 40 years?

Prasuna Reddy: I think the delayed gratification is an interesting one, because that is a good strategy. We could call it positive procrastination.

Norman Swan: You've got to get around to positive procrastination.

Prasuna Reddy: Well, yes you do, and again, it could be a habit. So rather than indulging in this wonderful chocolate cake that's in front of you, you could have it later. So there are strategies that we can use to change the habits that we have now. Patterns of control. The kinds of physical activity and diet changes require us to change our way of thinking. So we've got to focus or ignore something. It often requires changing the way that we are behaving. So things like removing unhealthy food from our immediate environment, those are simple strategies that can work.

Norman Swan: So cleaning out the fridge so there's no temptation.

Prasuna Reddy: Well, as best you can. And also being with people who are socially supportive of what you are doing. So changing our environments, changing our behaviour, changing the way that we are interacting with the things that we do.

Norman Swan: So this is the social contagion idea. If you associate with people who are doing the same things as you are, it's easier to do.

Prasuna Reddy: Yes.

Norman Swan: What do you advise people, Peter, when they are going to make these big changes?

Peter Clifton: I try not to make them big, because the bigger the change the harder it is to stick to, so just change one thing. So if you like eating chocolate, instead of having four squares, you have two, and you'd just…

Norman Swan: How do you do that?

Peter Clifton: Well, if you buy a nice expensive chocolate that has really got a great mouth-feel then you don't need more than two. But if you indulge in a cheap, sweet chocolate…

Norman Swan: Let me challenge you on that. There used to be a theory that you could get people off alcohol dependence by moderate drinking, you know, controlled drinking, and it has been shown to be a myth, that really if you are dependent on alcohol you've got to stop. If you are dependent on any drug, you've really got to stop, abstinence is really the only way. Can you control your chocolate intake really?

Peter Clifton: I think you can. I think alcohol is a particularly nasty drug in terms of dependence, particularly if you've got the gene for alcoholism. Food we have to eat every day, so it's not something we can avoid like alcohol, we have to be exposed to food all the time, so we just make choices about how big a serve size we have and make choices about the kind of food we choose. So we have to make choices all the time, we can't just avoid it.

Norman Swan: This is the Health Report coming to you live from the Powerhouse Museum in Sydney for the Ultimo Science Festival.

Bronwyn, you would start slowly with exercise? I mean, this notion that you've only got so much willpower and you've got to allocate it like two chocolate squares at a time…

Bronwyn Kingwell: Well, I see physical activity quite differently to diet. Whereas diet might be a deprivation, physical activity hopefully can turn into something that is a pleasurable activity. And I think the key is to choose something that you enjoy and to start off slowly, whether it be a walk or doing exercise in groups, as Prasuna said, so there is a social aspect to it as well. And then I think a lot of people can actually then start to enjoy the challenge of actually seeing physical improvements and being able to perform at a higher level. So I think the key really is to find activities that you enjoy.

Norman Swan: Prasuna, what is the role of the third party, whether that be a psychologist, a counsellor, a dietician, somebody…you know, in the case of Biggest Loser it's three trainers who shout and yell at you…the role of that person providing some external motivation. Does that detract from you learning self-control or does that beat new habits into you?

Prasuna Reddy: I would encourage having a social support, a trained person who can help you along the way.

Norman Swan: But you would, you're a clinical psychologist. But no, seriously, there is evidence…

Prasuna Reddy: But the person doesn't have to be a psychologist. To have a layperson, a good social support…I mean, it's incredible having an animal, for instance, what it does for people's activity and a sense of wanting to continue doing things that give them happiness.

Norman Swan: And if you are feeling low, it's quite hard to get…people say, 'Get out and exercise, you'll feel better,' but if you are feeling really low and you're depressed, it's quite hard to activate yourself to get out.

Prasuna Reddy: Well, what's really interesting is that when we ran our diabetes prevention programs, we were focused on evidence-based programs on physical activity and nutrition. We weren't focused on changing people's mental health, but we did measure depression and anxiety in the six sessions of the programs, and depression and anxiety significantly improved for people who were taking part in these group programs. Now, how do we understand that? Because we weren't targeting it, but what happened? There was group activity, there was a focus on physical activity, there was a focus on improving your nutrition. So we were working with the body, we were working with people in a social context. So it is possible to improve depression and anxiety through these programs.

Norman Swan: We've got a few minutes left in the program, if you want to ask a question raise your hand. Joel Werner from Off Track is here with a microphone and he will come to you while we are talking, so just raise your hand if you want to ask a question or even make a comment. Just make it short. We've got somebody in the front row there. Yes?

Audience member: I had a discussion with my son who is about 75 kilograms and about six-foot-five and he wants to bulk up, and he wants to do these protein shakes, he says he can get 1,000 calories in a meal. How do I stop him?

Peter Clifton: Why would you want to stop him? I mean, he's not going to put on muscle unless he does exercise. So just drinking protein will not put on any muscle at all. But if he exercises and takes the protein he will bulk up. But I don't think there's anything essentially wrong with that. It's not going to last unless he keeps doing it long term, but if he wants to do it to appear gorgeous for his girlfriend, fine.

Norman Swan: Bronwyn, what is the evidence on the combination of nutrition and exercise if your aim is strengthening your muscles?

Bronwyn Kingwell: I agree with what Peter said. If you are taking protein and you are doing high-level resistance exercise you will build muscle. The best way to build muscle is to lift really, really heavy weights, low repetitions, and the muscle will grow.

Norman Swan: Prasuna, tell me about activation therapy, because this is a way of…a relatively new psychotherapy, getting people going. What happens in it?

Prasuna Reddy: I don't know specifically about activation therapy in this context, but certainly any kind of event that can trigger behaviour change is going to help, and having the support to do it.

Norman Swan: So the event being somebody coming in and helping you out?

Prasuna Reddy: Yes. We underestimate the social influence of the media and others in what we do in our behaviour. And what we don't do is counter it with social support to activate the motivation. So my sense of it is that having anyone that will support you is going to be useful.

Norman Swan: So we are coming towards the end of the show. Bronwyn, what would be your key messages about exercise and getting off your bum, what you might do or what you might not do?

Bronwyn Kingwell: As I've said all the way through, I think it's very important that everybody does do some exercise. Exercise has so many effects on so many facets of health. The key is to find something that you enjoy, start off slowly, build up, and you'll find it's quite hard for the first few weeks, but once you've been going at it for four weeks or so, you'll start to find it become easier and easier, you'll start to see the improvements, and I think it then becomes easier to sustain.

Norman Swan: Peter Clifton?

Peter Clifton: In terms of lifestyle I think if you start slowly, you will adapt to it very easily, whether it's exercise or whether it's dietary changes…

Norman Swan: And don't expect quick weight loss, this is something…

Peter Clifton: Yes, certainly don't expect weight loss. The weight loss may take several years to happen, it might only be a kilo every three or four months, but as long as the changes you make are going to continue forever, it doesn't really matter the pace at which you do it.

Norman Swan: Prasuna?

Prasuna Reddy: I have two things that we found in our research actually keep people going. One is to keep track of what they are doing, so recording what you are eating, just having some idea of your exercise patterns and so on, just keeping track of what you are doing, and rewarding often. So thinking of ways that are not deprivation but rewarding what you are doing.